山区空巢老人慢性病管理带药上门随访模式研究  

Study on follow-up with drugs mode for chronic diseases management of empty nesters in mountain areas

作　　者：朱建良[1] 胡志勇[1] 刘晓红[1] 曾长佑[1] 王剑锋 徐艳 杨延平 ZHU Jian-liang;HU Zhi-yong;LIU Xiao-hong;ZENG Chang-you;WANG Jian-feng;XU Yan;YANG Yan-ping(Lishui Center for Disease Control and Prevention,Lishui,Zhejiang 323000,China;Zhucheng People’s Hospital of Shandong)

机构地区：[1]丽水市疾病预防控制中心,浙江丽水323000 [2]山东省诸城市人民医院

出　　处：《中国公共卫生管理》2020年第5期622-626,635,共6页Chinese Journal of Public Health Management

基　　金：浙江省医药卫生科技项目(2018KY941)。

摘　　要：目的了解山区空巢老人慢性病管理现状,探索空巢老人慢性病管理带药上门随访模式效果,为山区空巢老年人健康管理策略选择提供依据。方法抽取丽水市3个县(区)共12个行政村空巢老年慢性病患者240例,按行政村随机分为带药随访组和对照组,根据年龄和性别匹配,进行社会人口经济学特征、基本健康情况及SF-36量表调查,并进行1年队列跟踪研究,分析带药随访模式对患者的健康状况及血压血糖等控制效果的影响。采用方差分析、LSD-t检验及Wilcoxon秩和检验等统计方法进行分析。结果带药随访12个月后,两组间收缩压(t=5.135)、空腹血糖(t=4.241)和总胆固醇(t=4.967)的指标差异有统计学意义(P<0.05);而其他指标差异无统计学意义(P>0.05)。带药随访组高血压患者服药率由干预前的46.13%提高到72.24%,控制率由50.24%提高到56.12%,规范管理率由60.21%提高到67.32%,与对照组相比,服药率、控制率和规范管理率均明显提高,差异均有统计学意义(P<0.05)。带药随访干预12个月后,患者生理功能、精神健康和总体健康得分均高于对照组患者,差异均有统计学意义(P<0.05),而其他5个维度得分差异均无统计学意义(P>0.05)。结论通过慢性病管理带药上门随访模式实施,带药随访组患者的服药率、控制率及规范管理率等有较明显提高,并且总体健康情况有较大改善,此模式在山区欠发达地区慢性病管理方面具有较大推广价值。Objective To understand the current situation of chronic diseases management of empty nesters in mountain areas, and to explore the effect of follow-up with drugs mode for chronic diseases management of empty nesters, in order to provide the evidence for selecting health management strategies of empty nesters in mountain areas. Methods A total of 240 empty nest elderly patients with chronic diseases from 12 administrative villages in 3 counties(districts) of Lishui City were selected, and they were randomly divided into follow-up group and control group according to administrative villages. According to the match of age and gender, sociodemographic characteristics, basic health status and SF-36 scale were investigated. And one-year cohort tracking study was conducted to analyze the effects of follow-up with drugs mode on the patients’ health status and the control effect of blood pressure and blood glucose. Statistical methods such as analysis of variance, LSD-t test and Wilcoxon rank sum test were used for analysis. Results After 12 months of follow-up with drugs, there were significant differences in the indicators of systolic blood pressure(t=5.135), fasting blood glucose(t=4.241) and total cholesterol(t=4.967) between two groups(P<0.05);while other indicators showed no significant difference(P>0.05). In the follow-up group, the medication rate of the patients with hypertension increased from 46.13% to 72.24% after intervention, the control rate increased from 50.24% to 56.12%, and the standardized management rate increased from 60.21% to 67.32%. Compared with the control group, the medication rate, the control rate and the standardized management rate were all significantly increased, the differences were statistically significant(P<0.05). After 12 months of follow-up with drugs, the physiological function, mental health and overall health scores of the patients in the follow-up group were higher than those in the control group, the differences were statistically significant(P<0.05);while there were no sign

关 键 词：山区 空巢老人 带药随访 健康现况 

分 类 号：R197.1[医药卫生—卫生事业管理] R197.61[医药卫生—公共卫生与预防医学]